(Date)

Dear ______,

As part of our commitment to eradicate Central Line Associated Blood Stream Infections (CLABSI), we are performing a Root Cause Analysis of all CA-BSIs. Patient ______met CDC criteria for a CLABSI on (insert date and organism). Because the event occurred >48 from the time of line insertion, it is clear that this CLABSI is more likely related to maintenance. Therefore we are asking the clinical personnel who cared for this patient in the several days prior to the CLABSI to help us in our Root Cause Analysis. Take a moment to think about the (insert type of line) maintained from (insert dates of the 72 hour period before infection) and please let our team know about any factors you think could have introduced infection. If nothing particular stands out in your mind, please answer any of these questions that you are able to:

1.  Were there any observed breaches of proper hand hygiene by anyone involved in line care for this patient?

2.  Was the dressing integrity and change date assessed/addressed during your shift?

3.  If there was a dressing change on your shift, was 2% Chlorhexidine/70% alcohol used instead of iodine?

4.  Was the hub scrubbed with 70% alcohol or 2% Chlorhexidine/70% alcohol followed by air dry each time the line was accessed?

5.  Was this line manipulated/used by any other staff besides the unit’s physicians/nurses (e.g., anesthesia, radiology, etc)?

6.  If there was an IV administration sets change on your shift, were the old IV administration sets outdated (24 hours for lipids and blood, 96 hours for all others)?

7.  If you changed parenteral fluids on your shift, were the parenteral fluids you changed older than 24 hours?

8.  Was the necessity of lines for this patient discussed on daily patient rounds?

9.  What was the nursing ratio for this patient (e.g., 1:1, paired, etc)?

10.  Can you identify any other possible sources of contamination for the closed/sterile tubing-CVC circuit?

11.  Were there any mechanical problems with CVC prior to infection date? (not drawing, difficult to infuse, repositioned, etc)

12.  Are there any significant patient factors that you believe may have contributed to this infection?

13.  Are there any other issues related to central line care in the unit that you would like to share with the group?

Thank You,

The CLABSI Eradication Team